Barriers and enablers to the provision and receipt of preoperative pelvic floor muscle training for men having radical prostatectomy: a qualitative study

BMC Health Services Research Barriers and enablers to the provision and receipt of preoperative pelvic floor muscle training for men having radical prostatectomy: a qualitative study Andrew D Hirschhorn 0 1 Gregory S Kolt 1 Andrew J Brooks 2 0 Westmead Private Physiotherapy Services , Sydney , Australia 1 School of Science and Health, University of Western Sydney , Sydney , Australia 2 Western Urology , Sydney , Australia Background: Strong evidence exists to support preoperative pelvic floor muscle training (PFMT) to reduce the severity and duration of urinary incontinence after radical prostatectomy. Receipt of preoperative PFMT amongst men having radical prostatectomy in Western Sydney, however, is suboptimal. This study was undertaken to investigate barriers and enablers to provision/receipt of preoperative PFMT from the perspectives of potential referrers to and providers of PFMT, and of men having radical prostatectomy. Methods: A qualitative research design was used. Semi-structured, one-to-one interviews were conducted with participants from three groups: (i) current and potential referrers to PFMT, including urological cancer surgeons, urological cancer nurses and general practitioners (n = 11); (ii) current and potential providers of PFMT across public and private sector hospital and outpatient settings, including physiotherapists and continence nurses (n = 14); and (iii) men having had radical prostatectomy at a specific public and co-located private hospital in Western Sydney (n = 13). Interview schedules were developed using Michie's theoretical domains for investigating the implementation of evidence-based practice, and allowed participants to identify potential and actual barriers and enablers to preoperative PFMT. Transcribed interview data were analysed using a framework approach, and key themes were identified. Results: Participant groups concurred that a recommendation for PFMT from the urological cancer surgeon, accompanied with a referral to a specific provider, was a key enabler of preoperative PFMT. Perceived barriers varied between participant groups and across public and private healthcare settings. Perceptions of financial cost of private sector PFMT, limited knowledge amongst referrers of public sector providers of PFMT, and limited awareness amongst patients of the benefits of PFMT were all posited to contribute to suboptimal PFMT provision and receipt. Conclusions: This study has provided valuable data on barriers and enablers to preoperative PFMT, with implications for the planning of a behaviour change intervention to improve provision and receipt of preoperative PFMT in Western Sydney. Prostatectomy; Urinary incontinence; Translational research; Qualitative research; Physical therapy modalities - Background Prostate cancer is the most common form of malignancy in Australian men, with more than 20,000 new cases diagnosed in 2008 [1]. In approximately 90% of new prostate cancer diagnoses, the cancer is localised or locally advanced (i.e. the cancer is confined to the prostate gland or prostate region) [2]. Conventional treatments for localised prostate cancer include active surveillance, radical prostatectomy and radiotherapy (external beam and seed brachytherapy) [3]. While guidelines for choice of treatment are not clear-cut, radical prostatectomy may be preferentially indicated for patients with a greater life expectancy and who are fit for surgery [4]. The majority of men aged less than 70 to 75 years and diagnosed with localised prostate cancer, certainly in Australia and the USA, have radical prostatectomy as primary treatment [3,5]; more than 6,000 radical prostatectomies are performed in Australia annually [6]. Advantages of radical prostatectomy over active surveillance and radiotherapy include improved long-term cancer control and ability to determine prognosis according to pathologic cancer features [3]. Urinary incontinence, however, is a common complication of radical prostatectomy. The reported incidence of postprostatectomy urinary incontinence (PPUI) varies according to clinical definition and time of follow-up; recently published case-series report PPUI rates of 0 to 30% at twelve months after surgery (defined as using > 1 continence pad/day) [7], but up to 87% of patients report PPUI symptoms and/or bother at three months [8]. PPUI, whether transient or persistent beyond twelve months, reduces health-related quality of life, and may delay return to work and/or normal physical and social activity [9]. While the precise aetiology of PPUI may vary between patients, urodynamic studies demonstrate that bladder/ urethral sphincteric incompetence, resulting from surgical trauma, is a contributing factor in > 90% of cases [7]. Prolapse of the urethra through the pelvic floor may further impair residual sphincter function after radical prostatectomy [10]. Contraction of the pelvic floor muscles, specifically the rhabdosphincter-levator ani complex, moves to close and elevate the urethra, potentially compensating for this sphincter incompetence and dysfunction in periods of urinary stress. Hence pelvic floor muscle training (PFMT), whereby patients are taught by healthcare providers to voluntarily contract the pelvic floor muscles, with or without biofeedback, is a welldescribed conservative treatment for PPUI. While there is equivocal evidence of benefit for PFMT commenced after radical prostatectomy [8,11], there is increasing Level 1 evidence to support PFMT, commenced preoperatively, to reduce the severity and duration of PPUI [12-16]. Consequently, published recommendations for the conservative management of PPUI include that all men having radical prostatectomy receive preoperative PFMT, preferably from a physiotherapist or continence nurse [17]. Provision/receipt of preoperative PFMT for men having radical prostatectomy in Australia has not previously been reported. Preliminary audit data collected by the authors demonstrates, however, that in our clinical setting (i.e. a tertiary referral urological cancer centre in Western Sydney, Australia) approximately 60% of men having radical prostatectomy do not receive preoperative PFMT. Given significant urbanrural differences in access to other prostate cancer-related services in Australia [18], receipt of preoperative PFMT is likely to be even lower in settings outside major Australian cities. French et al. have described a systematic, four-step approach to developing theory-informed behaviour change interventions to implement evidence into clinical practice [19], e.g. to improve provision/receipt of preoperative PFMT. The first two steps of this approach are: (i) to identify the problem, i.e. identify who needs to do what differently; and (ii) to assess the problem, i.e. identify those local barriers and enablers that need to be addressed. In the present study, we investigated local barriers and enablers to preoperative PFMT amongst potential referrers (e.g. urological (...truncated)